Effect of Pre-Surgery Patient-Reported Outcomes and Surgeon Experience on Reoperation and Total Hip Replacement Rates Following Hip Arthroscopy

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1 Effect of Pre-Surgery Patient-Reported Outcomes and Surgeon Experience on Reoperation and Total Hip Replacement Rates Following Hip Arthroscopy Catherine J Bacon, Kirstie A Petch, Claudia R Brick, Joshua S Knudsen, Abbey C Lissaman, Matthew J Brick

2 Affiliations & Disclosures 1 Matthew J Brick MBChB FRACS Paid consultancy work: Stryker Received royalties: Arthrex 1,2,3 Catherine J Bacon BSc BPhEd (Hons) MSc PhD 1,5 Claudia R Brick Attended a clinical trials training course (2015) funded by Stryker 1,4 Joshua S Knudsen 1,5 Claudia R Brick 1 Kirstie A Petch 1 Abbey C Lissaman We (other authors) have no financial conflicts to disclose 1 Orthosports North Harbour, Auckland, NZ 2 Faculty of Medical and Health Sciences, University of Auckland, Auckland, NZ 3 Health Care (Osteopathy), Unitec Institute of Technology, Auckland, NZ 4 Orthopaedic Registrar 5 Medical Student

3 Background & Aims Growing evidence of outcomes of surgery for FAI Despite that there is a lack of information about patients who subsequently present for reoperative surgery or total hip arthroplasty (THA) Aim to determine whether same-joint reoperation or THA conversion rates (min 2y follow-up) are explained by: differences in patient characteristics experience over time of a single surgeon

4 Study Design & Surgery Selection INCLUSION CRITERIA Prospective & follow-up data collected as part of regular surgical audit Primary hip arthroscopies for FAI-related chondral and/or labral damage with/without corrective osteoplasty Sequential surgeries between June, 2005 to April, 2017

5 Outcomes Hip Pain and Function Questionnaires: International Hip Outcome Tool (IHOT12) Non-Arthritic Hip Score (NAH) Hip Disability and Osteoarthritis Outcome Score (HOOS) Visual Analogue Scale (VAS): normality and pain Patient Satisfaction: Would you have this surgery again? Pre-operative and Latest Follow-Up Scores used

6 Hip Characteristics Cohort 1558 surgeries (1296 patients) Age at Surgery (years) 35.0 ± 12.2 [13.2 to 70.7] BMI (kg/m 2 ) 25.2 ± 4.2 [14.2 to 42.9] Lateral CEA (degrees) 33.8 ± 6.2 [11 to 57] Gender: female / male 765 (49.1%) / 793 (50.9%) Side: left / right 708 (45.4%) / 850 (54.6%) Symptoms Onset: gradual / sudden 234 (41.2%) / 334 (58.8%) Funding: ACC (compulsory accident insurance) 436 (28.0%) private insurance 966 (62.2%) self-funding 112 (7.2%) charity 39 (2.5%) Osteoarthritis Classification: none / normal 240 (15.4%) early acetabular chondral delamination / wave sign 570 (36.7%) acetabular chondral delamination 1/3 from rim 290 (18.6%) acetabular chondral delamination 2/3 from rim 151 (9.7%) non-fai-related chondral damage: Tonnis Grade (12.9%) femoral head or acetabular pathology: Tonnis Grade >2 104 (6.7%) Data are mean ± SD or frequency (percentage of valid data)

7 Subsequent Surgery Revision or Reoperative Surgery Total (2 14 years)* 117 (7.5%) Within 2 Years 40 (2.6%) Years to Revision/Reoperation 2.82 ± 1.55 Conversion to Total Hip Joint Replacement* Total (2 14 years)* 56 (3.6%) Within 2 Years 30 (1.9%) Years to THJR 2.25 ± 1.86 Any Subsequent Surgery (same joint)* Total (2 14 years)* 169 (10.8%) Within 2 Years 70 (4.5%) Years to Subsequent Surgery 2.60 ± 1.66 Date are mean ± SD or frequency (%) *Follow-up: 5.4 ± 2.2 years [range: ]

8 Failure versus Non-Failure Pre-operative Differences Subsequent Surgery No Later Surgery P Value Age at Surgery (y) 37.4 ± ± * Body Mass Index (kg/m 2 ) 24.8 ± ± Lateral Centre Edge Angle (degrees) 33.2 ± ± Hip Scope Number 644 ± ± 478 <0.001** NAH Preop Score 58.4 ± ± ** IHOT12 Preop Score 36.3 ± ± Gender (female / male) 95 (56.2) / 74 (43.8) 670 (48.2) / 719 (51.8) 0.05 Symptoms Onset (gradual / sudden) 32 (45.7) / 38 (54.3) 202 (40.6) / 296 (59.4) 0.3 Osteoarthritis Signs 57 (34.1; rate 18.8%) 247 (17.8) <0.001** Date are mean ± SD or frequency (% of those with or without subsequent surgery)

9 2-year Failure versus Non-Failure Pre-operative Differences Subsequent Surgery No Later Surgery P Value Age at Surgery (y) 40.0 ± ± ** Body Mass Index (kg/m 2 ) 24.5 ± ± Lateral Centre Edge Angle (degrees) 31.4 ± ± ** Hip Scope Number 769 ± ± NAH Preop Score 58.1 ± ± IHOT12 Preop Score 36.1 ± ± Gender (female / male) 42 (60.0) / 28 (40.0) 723 (48.6) / 765 (51.4) 0.06 Symptoms Onset (gradual / sudden) 15 (60.0) / 10 (40.0) 219 (40.3) / 324 (59.7) 0.2 Osteoarthritis Signs 27 (39.1; rate 8.9%) 277 (18.6) <0.001** Date are mean ± SD or frequency (% of those with or without subsequent surgery)

10 2-Year Failure Rate (%) Effect of Surgeon Experience Hip Scope Number for Surgeon

11 NAH Total Score IHOT12 Total Score Effect of Surgeon Experience: Non-Arthritic Hip & IHOT12 Scores First 250 Hip Scopes Later Hip Scopes Pre-Op Follow-Up Pre-Op Follow-Up Error bars are 95% confidence intervals (NS interaction effects)

12 Effect of Surgeon Experience: Patient Satisfaction Would you have the operation again if needed on another joint? 13.8% 3.8% 2.7% 9.9% Definitely Yes Probably Yes Possibly Not Definitely Not 24.6% 57.7% 29.3% 58.1% (p = 0.4) First 250 Scopes vs Later Scopes Significance is Chi-Squared Test showing difference in proportions between groups

13 Conclusions Results show a low 2-year rate (4.5%) of surgical failure, defined as any reoperative surgery or conversion to total hip joint replacement on or around the same hip joint, following primary hip arthroscopy. The rate increases to 10.8% with average 5.4 year follow-up. Hips that failed, as defined above and corrected for follow-up time, occurred in: older patients, those with lower LCEA, and those with signs of osteoarthritis developing outside of the direct area of damage from the FAI morphology any non-fai-related chondral damage (Tonnis > 0) doubled the risk of failure non-significant trends for failure to occur in females compared to males and in those with lower pre-operative NAH total scores We have not found an effect of surgeon experience when failure rate is corrected for follow-up time.